Out with the old, in with the new? The revised AAST grading schema better predicts splenic salvage but not splenectomy.

BACKGROUND: The revised American Association for the Surgery of Trauma (AAST) organ injury scale (OIS) for splenic injury incorporates radiologic features but the implications of this are unknown. We hypothesized that the revised AAST-OIS would better predict outcomes. METHODS: Patients with a blunt splenic injury admitted to a Level I trauma center were reviewed from 2016 to 2021. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for splenectomy were calculated for high-grade injuries (AAST-OIS grades IV-V) using both schemas. RESULTS: Of the 852 patients analyzed, 48.5% were observed, 24.6% were embolized, and the remaining underwent operative intervention. The median AAST-OIS increased from II to III (p â€‹< â€‹0.01). Sensitivity (38.0% vs. 73.7%) and NPV (80.9% vs. 88.2%) for splenectomy increased for high-grade injuries but specificity (93.5% vs 70.1%) and PPV (67.5% vs 46.7%) decreased. CONCLUSION: The revised AAST-OIS better predicted splenic salvage but is less accurate at predicting need for splenectomy.

More Harm Than Good: It is Time to Reconsider Prophylactic Fasciotomy in Lower-Extremity Vascular Injury.

INTRODUCTION: Four-compartment calf fasciotomy (CF) can be limb-saving. Prophylactic fasciotomy (PP) is advised in high-risk situations to prevent limb loss. Calf fasciotomy can cause significant morbidity, particularly if performed unnecessarily. We hypothesized that selective use of fasciotomies (SF) after lower-extremity vascular injury would lead to a lower rate of overall fasciotomies without an increase in limb complications than prophylactic fasciotomies (PFs). METHODS: Trauma patients who sustained lower-extremity vascular injury that required operative repair at a high-volume trauma center were retrospectively reviewed and grouped by SF or PF (2016-2022). SF were individuals who were observed and underwent CF only if signs of compartment syndrome developed, whereas PF were individuals who underwent CF without signs of compartment syndrome. The primary outcome was amputation rate. Secondary outcomes were fasciotomy rate, need for reoperative vascular surgery, and clinical characteristics predisposing use of PF. RESULTS: Of 101 overall patients, 30 patients (29.4%) had PF. Of the remaining 71 (SF group), 43.7% (n = 31) were spared CF. The median time from injury to vascular repair in both groups was the same (7 hours, P = .15). There was no difference in rate of vascular reoperation per group (PF = 26.7% vs SF = 23.9%, P = .77). The only clinical characteristic associated with PF was need for arterial shunt (OR 4.2, P = .028). CONCLUSIONS: In trauma patients with lower-extremity vascular injury undergoing vascular repair, selective use of fasciotomy can spare almost half of patients the need for fasciotomy without an increase in limb complications.

Youth Violence Does not Discriminate: Inclusive Violence Prevention Support Services Focused on Counseling and Peer Support are Essential for Youth and Young Adults.

BACKGROUND: Violence disproportionately affects individuals of low socioeconomic status, and rates of injury amongst youth and young adults (YYAs) are rising. Little is known about how the social needs of this high-risk subgroup compared to the overall violently injured population. METHODS: This is a retrospective review of an intake assessment of violently injured victims admitted to a level I trauma center (Jan 2022-Aug 2023). Data collected include race, age, mechanism of injury, and protective and predisposing factors for violent injury. We compared the risk factors of YYAs (=≤ 24 years) to those of adults (>24) and evaluated rates and types of violence prevention services requested by age group. RESULTS: Of 350 individuals surveyed, 94 (27%) were <= 24 years and 256 (73%) were >24 years. Younger patients were less likely to be male (77% vs 86%, P = .03) and experienced more firearm injury (76% vs 51%, P < .001). They reported less alcohol use (20% vs 38%, P < .001), similar rates of mental illness (25% vs 26%, P = .62), less housing instability (5% vs 22%, P < .001), and similar access to government benefits (20% vs 29%, P = .2) compared to the older cohort. Services were requested by 41% of the study population (N = 142); the younger cohort was 2.9 times more likely to request non-financial services (P = .042). DISCUSSION: Violently injured youth and young adults (YYAs) experience disproportionately high rates of gun violence. Efforts should be made to prioritize legal, peer support, and mental health services over financial services for this population.

To Drain or Not: Drainage Procedures Remain a Central Tenet of Management of Infected Collections in Acute Pancreatitis.

Recent literature advocates for delayed or avoidance of catheter drainage of infected peri-pancreatic collections (IPCs) in acute pancreatitis (AP). This may not be realistic for patients at academic centers, many of whom are critically ill. We retrospectively reviewed 72 patients admitted to our institution from 2016-2021 with AP and IPCs. 34.7% had a Bedside Index of Severity in Acute Pancreatitis (BISAP) score ≥3, and 56.9% had a Balthazar score of E. 65.3% were admitted to the ICU, 51.4% experienced respiratory failure, and 47.2% had acute renal failure. In-hospital mortality was 9.7%. Catheter-based drainage alone was the most frequent intervention. Only 8 individuals did not undergo any drainage. Individuals with severe AP complicated by IPCs are critically ill. Avoidance or delay of source control could lead to significant morbidity. Until further research is done on this population, drainage should remain a central tenet of management of IPCs.

Size of Splenic Subcapsular Hematoma Is Associated With Varying Outcomes of Nonoperative Management.

The presence of a splenic subcapsular hematoma (SCH) has been associated with higher rates of failure of nonoperative management (FNOM) in patients with blunt splenic injury (BSI), with rates up to 80%. We hypothesized that contemporary rates are lower. A retrospective review was conducted of patients admitted with BSI to a level I trauma center (2016-2021). Patients with SCH who had FNOM were compared to those who did not. There were 661 BSI patients, of which 102 (15.4%) had SCH. Among the SCH patients, 8 (7.8%) had FNOM. Failure of nonoperative management was higher in patients who had a SCH measuring 15 mm or greater. To the best of our knowledge, this is the largest study to date examining the relationship between SCH and FNOM. The presence of a SCH alone is not associated with a high risk for FNOM contrary to previous literature. However, SCH thickness was larger in those who failed.

A pseudo-dilemma: Are we over-diagnosing and over-treating traumatic splenic intraparenchymal pseudoaneurysms?

BACKGROUND: Splenic embolization for traumatic vascular abnormalities in stable patients is a common practice. We hypothesize that modern contrast-enhanced computed tomography (CT) over diagnoses posttraumatic splenic vascular lesions, such as intraparenchymal pseudoaneurysms (PSA) that may not require embolization. METHODS: We reviewed the experience at our high-volume center with endovascular management of blunt splenic injuries from January 2016 to December 2021. Multidisciplinary review was used to compared initial CT findings with subsequent angiography, analyzing management and outcomes of identified vascular lesions. RESULTS: Of 853 splenic injuries managed overall during the study period, 255 (29.9%) underwent angiography of the spleen at any point during hospitalization. Vascular lesions were identified on 58% of initial CTs; extravasation (12.2%) and PSA (51.0%). Angiography was performed a mean of 22 hours after admission, with 38% done within 6 hours. Embolization was performed for 90.5% (231) of patients. Among the 130 patients with PSA on initial CT, 36 (27.7%) had no visible lesion on subsequent angiogram. From the 125 individuals who did not have a PSA identified on their initial CT, 67 (54%) had a PSA seen on subsequent angiography. On postembolization CT at 48 hours to 72 hours, persistently perfused splenic PSAs were seen in 41.0% (48/117) of those with and 22.2% (2/9) without embolization. Only one of 24 (4.1%) patients with PSA on angiography observed without embolization required delayed splenectomy, whereas 6.9% (16/231) in the embolized group had splenectomy at a mean of 5.5 ± 4 days after admission. CONCLUSION: There is a high rate of discordance between CT and angiographic identification of splenic PSAs. Even when identified at angiogram and embolized, close to half will remain perfused on follow-up imaging. These findings question the use of routine angioembolization for all splenic PSAs. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Greater cost without greater benefit: The need to refine transfer criteria for patients with severe acute pancreatitis.

BACKGROUND: Appropriate and timely care is essential in the management of severe acute pancreatitis (SAP). We hypothesized that transferred patients with SAP undergoing procedural intervention would have higher mortality compared to those managed directly at academic centers. METHODS: This was a retrospective analysis of Maryland's statewide claims database from 2009 to 2022 of adult patients admitted with a primary diagnosis of SAP (acute pancreatitis with organ failure). Patients were divided into three groups: those admitted directly from the emergency room to academic facilities (AD), non-academic facilities (NA), or transferred to academic facilities (TR). Procedural intervention included endoscopic, percutaneous image-guided, or surgical. The primary outcome was in-hospital mortality. Secondary outcomes were admission costs, length of stay (LOS), and intensive care unit (ICU) admission. RESULTS: There were 7,648 (48.9%) in the NA group, 6,682 (42.7%) in the AD group and 1,316 (8.4%) in the TR group. On regression analysis, odds of death were 0.57x lower in the NA group and 0.67x lower in the AD group compared to transfers (<0.001). Procedural intervention was not associated with increased mortality. Transferred patients had longer median LOS (11 vs NA = 5, AD = 6, p < 0.001), increased median cost of admission ($41k vs NA = $12k, AD = $17k, p < 0.001) and greater ICU admission (45.6% vs NA = 20.6%, AD = 23.9%, p < 0.001). CONCLUSION: Transferred patients have greater burden of illness and cost of care without evidence of improved outcomes in the management of SAP regardless of procedural intervention. Transfer criteria for patients with SAP must be further refined to reduce unnecessary transfers.

Time to Splenic Angioembolization Does Not Impact Splenic Salvage Rates.

We aimed to determine whether early (<6 hours) vs delayed (≥6 hours) splenic angioembolization (SAE) after blunt splenic trauma (grades II-V) impacted splenic salvage rates at a level I trauma center (2016-2021). The primary outcome was delayed splenectomy by timing of SAE. Mean time of SAE was determined for those who failed vs those who had successful splenic salvage. We retrospectively identified 226 individuals, from which 76 (33.6%) were in the early group and 150 (66.4%) were in the delayed group. The early group had higher AAST grade, greater amount of hemoperitoneum on CT, and 3.9x greater odds of undergoing delayed splenectomy (P = .046). Time to embolization was shorter in the group that failed splenic salvage (5 vs 10 hours, P = .051). On multivariate analysis, timing of SAE had no effect on splenic salvage. This study supports performing SAE on an urgent rather than emergent basis in stable patients after blunt splenic injury.

A Cautionary Tale: The Use of Propensity Matching to Evaluate Hemorrhage-Related Trauma Mortality in the American College of Surgeons TQIP Database.

BACKGROUND: Propensity-matched methods are increasingly being applied to the American College of Surgeons TQIP database to evaluate hemorrhage control interventions. We used variation in systolic blood pressure (SBP) to demonstrate flaws in this approach. STUDY DESIGN: Patients were divided into groups based on initial SBP (iSBP) and SBP at 1 hour (2017 to 2019). Groups were defined as follows: iSBP 90 mmHg or less who decompensated to 60 mmHg or less (immediate decompensation [ID]), iSBP 90 mmHg or less who remained greater than 60 mmHg (stable hypotension [SH]), and iSBP greater than 90 mmHg who decompensated to 60 mmHg or less (delayed decompensation [DD]). Individuals with Head or Spine Abbreviated Injury Scale score 3 or greater were excluded. Propensity score was assigned using demographic and clinical variables. Outcomes of interest were in-hospital mortality, emergency department death, and overall length of stay. RESULTS: Propensity matching yielded 4,640 patients per group in analysis #1 (SH vs DD) and 5,250 patients per group in analysis #2 (SH vs ID). The DD and ID groups had 2-fold higher in-hospital mortality than the SH group (DD 30% vs 15%, p < 0.001; ID 41% vs 18%, p < 0.001). Emergency department death rate was 3 times higher in the DD group and 5 times higher in the ID group (p < 0.001), and length of stay was 4 days shorter in the DD group and 1 day shorter in the ID group (p < 0.001). Odds of death were 2.6 times higher for the DD vs SH group and 3.2 times higher for the ID vs SH group (p < 0.001). CONCLUSIONS: Differences in mortality rate by SBP variation underscore the difficulty of identifying individuals with a similar degree of hemorrhagic shock using the American College of Surgeons TQIP database despite propensity matching. Large databases lack the detailed data needed to rigorously evaluate hemorrhage control interventions.

Surveillance Imaging Associated With Delayed Splenectomy in High-Grade Blunt Splenic Trauma.

This retrospective, single-site study at a level I trauma center (2016-2021) sought to determine whether repeat CT had an impact on clinical decision making after splenic angioembolization following blunt splenic trauma (grades II-V). The primary outcome was need for intervention after subsequent imaging (defined as angioembolization and/or splenectomy) by high- or low-grade injury. Of the 400 individuals examined, 78 (19.5%) underwent intervention after repeat CT, from which 17% were in the low-grade group (grades II and III) and 22% were in the high-grade group (grades IV and V). Individuals in the high-grade group were 3.6 times more likely to undergo delayed splenectomy than those in the low-grade group (P = .006). Delayed intervention after surveillance imaging in blunt splenic injury is driven mostly by the identification of new vascular lesions and leads to greater rates of splenectomy in high-grade injuries. Surveillance imaging should be considered for all AAST injury grades II or higher.

Geospatial analysis of firearm injuries in an urban setting: Individual rather than community characteristics affect firearm injury risk.

BACKGROUND: The relationship between individual/socioeconomic characteristics and firearm injury risk in an urban center was evaluated. METHODS: A hospital registry was used to identify individuals in Baltimore City who experienced interpersonal firearm injury in 2019 (FA). Injuries that did not satisfy this criterion were used as a comparison group (NF). Socioeconomic characteristics were linked to home address at the block group level. Regression analysis was used to determine predictors of firearm injury. Clusters of high and low firearm relative to non-firearm injuries were identified. RESULTS: A total of 1293 individuals were included (FA = 277, NF = 1016). The FA group lived in communities with lower income (p = 0.005), higher poverty (p = 0.007), and more Black residents (p < 0.001). Individual level factors were stronger predictors of firearm injury than community factors on multivariate regression with Black race associated with 5x higher odds of firearm injury (p < 0.001). Firearm injury clustered in areas of low socioeconomic status. CONCLUSIONS: Individual versus community factors have a greater influence on firearm injury risk. Prevention efforts should target young, Black men in urban centers.

Not All Fluid Collections Are Created Equal: Clinical Course and Outcomes of Pancreatic Pseudocysts and Acute Peripancreatic Fluid Collections Requiring Intervention.

BACKGROUND: Knowledge on pancreatic pseudocyst (PP) management has mostly involved large database analysis, which limits understanding of a complex and heterogeneous disease. We aimed to review the clinical course and outcomes of PP and acute peripancreatic fluid collections (APFC) that require intervention at 1 high-volume center. METHODS: Retrospective review of patients with APFC and PP undergoing drainage (2011-2018) was performed. Patients were divided into groups based on initial intervention: surgical (SR), percutaneous (PC), or endoscopic (EN) drainage. Primary outcome was mortality by initial intervention type. Secondary outcomes included subsequent interventions required, length of stay (LOS), readmission rates, and discharge disposition. RESULTS: Of 88 patients, 40 (46.1%) underwent SR, 40 (44.9%) PC, and 8 (9.0%) EN. No patients in EN group had APACHE II scores>20. Pancreatic necrosis was higher in SR (80.5%) and PC (62.5%) groups (P = .006). There were no differences in mortality, LOS, or readmission rates. Ten patients in the PC group underwent subsequent surgical intervention, of which 9 were due to bowel ischemia. The PC group was 3.4 times more likely to be discharged to rehabilitation over home when compared to the other 2 groups (P = .04). CONCLUSION: Patients undergoing surgical or percutaneous drainage of APFC and PP have a greater burden of illness and more local complications requiring intervention compared to endoscopic drainage. The heterogeneity in presentation of peripancreatic fluid collections in acute pancreatitis must be considered when evaluating the benefits of each intervention.

Surgical Stabilization of Rib Fractures in Severe Injury Is Not Associated With Worse Outcomes.

INTRODUCTION: This study aimed to determine whether surgical stabilization of rib fractures (SSRF) is associated with worse outcomes in individuals with multicompartmental injuries. MATERIALS AND METHODS: A retrospective review of a prospective trauma registry was performed for adult blunt trauma patients (aged ≥ 18 y) with Injury Severity Score ≥ 15 and radiographic evidence of rib fractures (2015-2020). Individuals without concomitant head, abdomen/pelvis, or lower extremity Abbreviated Injury Scale scores ≥ 3 were excluded. Propensity match on demographic and clinical variables was performed comparing patients treated nonoperatively (NO) to those undergoing SSRF. A chart review was performed for additional data. Primary outcome was hospital length of stay (LOS). Secondary outcomes were in-hospital mortality, intensive care unit LOS, and duration of mechanical ventilation. RESULTS: One thousand nine hundred ninety three patients fit the inclusion criteria (NO = 1,951, SSRF = 42). After matching, there were 98 in the NO group and 42 in the SSRF group. Mean age was 51 y, 61.4% were male, and 71.4% were of White race. Median time to fixation was 5 d. The SSRF group had more severe chest trauma as evidenced by a higher RibScore (3.2 versus 1.7, P < 0.001) and had a longer LOS (18 versus 9 d, P < 0.001), intensive care unit LOS (13 versus 3 d, P = 0.007), and duration of mechanical ventilation (8 versus 2 d, P = 0.013) on univariate analysis. Multivariable regression analysis demonstrated no association between SSRF and these short-term outcomes. CONCLUSIONS: Despite delayed average time to intervention, SSRF in a trauma-patient population with multicompartmental injuries and competing management priorities is not associated with worse short-term outcomes.

Implementation of an Outpatient Violence Intervention Program to Increase Service Uptake.

Challenges in participant recruitment and retention limit the effectiveness of hospital-based violence intervention programs (HVIPs). This study aimed to determine if an outpatient violence intervention program (VIP) could be integrated into a trauma clinic and increase uptake of violence prevention services. Patients previously hospitalized for intent-to-harm being seen for outpatient follow-up were eligible. VIP counselors met with participants during their clinic visit, administered the survey, and offered violence prevention services (April to June 2019). Patients were followed for 6 months to assess involvement. The primary outcome of interest was long-term participation in the VIP, defined as uptake of services at 6 months, in comparison to inpatient recruitment. Out of 76 patients, 34 (44.7%) did not appear for their appointment. The remainder (n = 42) were offered participation in the study, of which 32 (76.2%) completed the survey. From the group offered VIP services, 57.1% expressed interest, and 5 (20.8%) ultimately took part yielding an overall participation rate of 11.9% at 6 months. The inpatient recruitment rate in 2019 was 2.4%. An outpatient VIP program can be integrated into a clinic setting but suffers from the same challenges faced by inpatient programs resulting in low rates of long-term participation in services. Although a high proportion of participants reported interest, actual engagement at 6 months was low. Reasons behind low participation in VIP services must be investigated.

Exploring emergent barriers to hospital-based violence intervention programming during the COVID-19 pandemic.

National rates of gun violence have risen during the COVID-19 pandemic. There are many contributing factors to this increase, including the compounding consequences of social isolation, unstable housing, decreased economic stability, and ineffective and violent policing of communities of color. The effects of these factors are exacerbated by the pandemic's impact on the provision and availability of psychosocial services for individuals in marginalized communities, particularly those who have been violently injured. Hospital-based violence intervention programs (HVIPs) have been identified as a crucial intervention strategy in reducing repeat violent injury. The ongoing COVID-19 pandemic has engendered, significant barriers in HVIPs' attempts to assist program participants in achieving their health-related and social goals. This research offers insight into the complexities of providing social services during the convergence of two public health crises-COVID-19 and gun violence-at the HVIPs associated with the two busiest trauma centers in the state of Maryland. In considering the effects of inadequate financial support and resources, issues with staffing, and the shift to virtual programming due to restrictions on in-person care, we suggest possible changes to violence prevention programming to increase the quality of care provided to participants in a manner reflective of their unique structural positions.

Update on Nonoperative Management of the Injured Spleen.

Despite significant interest in trauma to the spleen over the past 130 years, splenectomy remained the preferred approach to splenic injures in children till the late 1950s and even later in adults. With recognition of the immunologic importance of the spleen and improvements in diagnostic imaging and angioembolization, there are now four pathways for the child or adult admitted with a possible, likely, or diagnosed injury to the spleen. These include the following: (1) operation with splenectomy; (2) operation with splenorrhaphy or partial splenectomy; (3) nonoperative management (observation); and (4) nonoperative management with splenic arteriography and possible angioembolization. This review will focus on the latter two options.

Influence of Covid-19 Restrictions on Urban Violence.

We investigated whether the COVID-19 pandemic affected rates of interpersonal violence (IV). A retrospective study was performed using city-wide crime data and the trauma registry at one high-volume trauma center pre-pandemic [PP] (March-October 2019) and during the pandemic [PA] (March-October 2020). The proportion of trauma admissions attributable to IV remained unchanged from PP to PA, but IV increased as a proportion of overall crime (34% to 41%, p<0.001). Assaults decreased, but there was a proportionate increase in penetrating trauma which was mostly attributable to firearms. Despite a reduction in admissions due to IV in the first 4 months of the pandemic, the rates of violence subsequently exceeded that of the same months in 2019. The cause of the observed increase of IV is multi-factorial. Future studies aimed at identifying the root causes are essential to mitigate violence during this ongoing health crisis.